Maas
Attorney
Intake
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MT-10
Elmiron Intake
Fill in every section. Required fields are marked *.
MT-10
Elmiron
Qualifying
1
Center information
Center Code
Enter your center code
Agent Name
Required
TF Link
(TrustedForm certificate URL)
Paste the TrustedForm certificate link (https://cert.trustedform.com/…)
Call type
Select...
Inbound
Outbound
Live transfer
Callback
Required
Lead source / publisher
(optional)
Required
2
Qualification
Are you currently represented by an attorney for this matter?
Select...
Yes
No
Required
DQ: Represented by attorney
Have you spoken to or signed with another law firm about this before?
Select...
No
Spoke with one – did not sign
Signed before – case was dropped
Required
Have you already settled or signed a release for this injury?
Select...
No
Yes
Required
DQ: Already settled / released
Have you been convicted of a felony?
Select...
Yes
No
Required
Have you filed for bankruptcy since the injury / diagnosis?
Select...
No
Yes
Not sure
Required
3
Client information
Client First Name
Required
Middle Name
Required
Client Last Name
Required
Suffix
Select...
Jr.
Sr.
II
III
IV
Required
Gender
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Female
Male
Non-binary
Prefer not to say
Required
Birthdate
Valid birthdate required (18+)
Marital status
Select...
Single
Married
Divorced
Widowed
Separated
Required
Client Street (Primary)
Required
Apt / Unit
Required
Client City (Primary)
Required
Client State (Primary)
Select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Required
Client Zip Code (Primary)
5-digit ZIP
Client Phone (Primary)
(10 Digit Number Only - No Hyphens or Parenthesis)
Enter exactly 10 digits
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Alternate Phone
Enter exactly 10 digits
Client Email (Primary)
Enter a valid email
Best time to call
Select...
Morning
Afternoon
Evening
Any time
Required
Preferred language
Select...
English
Spanish
Other
Required
4
Injured person
Is the client the injured person?
Select...
Yes – the client is the injured person
No – calling on behalf of a living person
No – the injured person has passed away
Required
Injured person's full name
Required
Injured person's date of birth
Required
Client's relationship to the injured person
Select...
Spouse
Parent
Child
Sibling
Legal guardian
Power of attorney
Other family
Other
Required
Date of death
Required
Cause of death (per death certificate)
Required
Is the client the executor / estate representative?
Select...
Yes
No
Not yet appointed
Required
5
Medical & insurance
Main treating doctor / hospital (name & city)
Required
Primary care doctor (name & city)
Required
Pharmacy used (name & city)
Required
Health insurance
Medicare
Medicaid
Private / employer
VA / Tricare
None
Select at least one
6
MT-10 · Elmiron questions
Did you take Elmiron (pentosan polysulfate) for interstitial cystitis / bladder pain?
Select...
Yes
No
Required
DQ: No Elmiron use
How long did you take it?
Select...
Less than 1 year
1 – 2 years
3 – 5 years
5+ years
Required
Years of use
(e.g. 2012 – 2019)
Required
Eye / vision diagnosis
Select...
Pigmentary maculopathy
Retinal damage / maculopathy
Macular degeneration
Vision loss / trouble reading or seeing in dim light
No eye diagnosis
Required
DQ: No eye injury
Date of eye diagnosis
Required
Eye doctor / clinic
Required
7
Case summary & documents
Case summary – what happened, in the client's own words
Required
Documents the client has or can get
Pharmacy records showing Elmiron
Eye exam / retina (OCT) records
Urology records
Photo ID
None yet
Select at least one
Upload documents
(optional – attach anything the client has already sent)
📎 Click to attach documents
or drag files here
PDF, photos (JPG / PNG / HEIC), Word · up to 10 files · 10 MB each
Check the files: max 10 files, 10 MB each
Agent notes
(internal)
Required
Submit lead
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Submitted
Lead ID
Submit another Elmiron lead